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A4056 - Diffuse Large B-Cell Lymphoma Presenting as Diffuse Alveolar Hemorrhage
Author Block: G. Al-Helou1, A. Jose1, A. W. McLean1, K. Dodds2, J. E. Ahari1, G. Gutierrez1; 1Pulmonary, Critical Care, and Sleep Medicine, George Washington University MFA, Washington, DC, United States, 2Internal Medicine Department, George Washington University MFA, Washington, DC, United States.
Introduction: Diffuse Alveolar Hemorrhage is a rare but life-threatening condition usually associated with infections, toxins, inflammatory diseases, or coagulopathies. Prognosis primarily depends on etiology and severity of the initial presentation. Case Presentation: A 58-year-old woman with a past medical history significant for breast cancer status-post curative lumpectomy two years prior presented to the emergency department with several weeks of fatigue and malaise.
Vital signs were notable for tachycardia and tachypnea. Significant splenomegaly was present on physical exam which was otherwise non-revealing. Initial hematologic evaluation revealed anemia and thrombocytopenia. Reticulocyte count was low, but iron and vitamin B12 levels were normal. Following transfusion of two units of packed red blood cells, the patient developed dyspnea and hypoxemia. Chest radiography showed diffuse opacities bilaterally, and the patient received broad-spectrum antibiotics and diuretics without clinical improvement. Due to her progressive hypoxemic respiratory failure, she was intubated and initiated on mechanical ventilation. A bronchoscopy was subsequently performed; serial broncho-alveolar lavages showed increasing bloody effluent suggestive of diffuse alveolar hemorrhage. No definitive cause of alveolar hemorrhage was identified, even after diagnostic testing including a complete rheumatological, coagulopathic, and cardiovascular workup. Given the significant hypoxemia, high dose corticosteroid therapy was initiated with rapid clinical improvement followed by successful extubation two days later. A bone marrow biopsy done to evaluate for hematological malignancy was unremarkable. However, following a period of overall clinical improvement, the patient developed severe left-sided flank pain and anemia. Computed tomographic scanning showed spontaneous splenic rupture, and an emergent splenectomy was performed. Pathologic examination of the explanted tissue revealed red pulp infiltration by large atypical cells suggestive of diffuse large B-Cell lymphoma (positive for CD19 and CD20 cell surface markers). The patient was placed on oral corticosteroid therapy post-splenectomy, improved, and was discharged with outpatient oncology follow up. Discussion: Diffuse alveolar hemorrhage has been described following treatment for lymphoma, commonly with bone marrow transplant or rituximab therapy in the setting of significant cytopenias. To our knowledge, diffuse alveolar hemorrhage as the presenting symptom of lymphoma in the setting of relatively normal hematological and coagulation parameters has not been previously described in the literature.